Travel Questionnaire Surname Forename(s) Date of Birth GP Consent for storing submitted data Consent for storing submitted data Please list the countries to be visited and length of stay, including any stopovers? (stopovers should include short stays in airport terminals) Will you be travelling to your destination by: Aeroplane Boat Car Train Bus Other Other (please specify) : What type of transport do you expect to use while abroad? (local buses, car hire, renting mopeds or bicycles) Are you planning/anticipating doing any sporting activities? Yes No If Yes, please specify: Where do you intend to stay while abroad? (e.g. International/budget hotels, guest houses, camping or with friend/relative) What is the purpose of your Travel? Holiday Visiting relatives/friends Work Other Work (Please specify) Other (Please specify) Have you had any of the following? (Please select those that apply) Heart problems Splenectomy Allergies Diabetes Chemotherapy Asthma Other Other (Please specify) Have you recently had any illness or dental treatment? No Yes Yes (Please specify) Are you pregnant? Yes No Are you currently on any medication? Yes No Yes (Please list any medication you are currently taking)